Health Care Eligibility Benefit Response (X279A1)

Eligibility, Coverage or Benefit Information (271)

ANSI ASC X12.281 Eligibility, Coverage, or Benefit Inquiry (270) and ANSI ASC X12.282 Eligibility, Coverage, or Benefit Information (271) mandated under HIPAA through June 2010

No Authorization Information Present (No Meaningful Information in I02)

Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003

No Security Information Present (No Meaningful Information in I04)

ST*271*4321*005010X279A1~
BHT*0022*11*10001234*20060501*1319~
HL*1**20*1~
NM1*PR*2*ABC COMPANY*****PI*040~
HL*2*1*21*1~
NM1*1P*2*BONE AND JOINT CLINIC*****SV*2000035~
HL*3*2*22*0~
TRN*2*93175-012547*9877281234~
NM1*IL*1*SMITH*JOHN****MI*123456789~
N3*15197 BROADWAY AVENUE*APT 215~
N4*KANSAS CITY*MO*64108~
DMG*D8*19630519*M~
DTP*346*D8*20060101~
EB*1**30**GOLD 123 PLAN~
EB*L~
EB*1**1^33^35^47^86^88^98^AL^MH^UC~
EB*B**1^33^35^47^86^88^98^AL^MH^UC*HM*GOLD 123 PLAN*27*10*****Y~
EB*B**1^33^35^47^86^88^98^AL^MH^UC*HM*GOLD 123 PLAN*27*30*****N~
LS*2120~
NM1*P3*1*JONES*MARCUS****SV*0202034~
LE*2120~
SE*22*4321~


Example 1a: Response to a Generic Request by a Clinic for the Patient’s (Subscriber) Eligibility

ST*271*4323*005010X279A1~
BHT*0022*11*10001234*20060501*1319~
HL*1**20*1~
NM1*PR*2*ABC COMPANY*****PI*040~
HL*2*1*21*1~
NM1*1P*2*BONE AND JOINT CLINIC*****SV*2000035~
AAA*Y**50*N~
SE*8*4323~


Example 1b: Error Response from Payer to Clinic Not Eligible for Inquiries with Payer

ST*271*4322*005010X279A1~
BHT*0022*11*10001235*20060501*1319~
HL*1**20*1~
NM1*PR*2*ABC COMPANY*****PI*040~
HL*2*1*21*1~
NM1*1P*2*BONE AND JOINT CLINIC*****SV*2000035~
HL*3*2*22*1~
NM1*IL*1*SMITH*JOHN****MI*123456789~
N3*15197 BROADWAY AVENUE*APT 215~
N4*KANSAS CITY*MO*64108~
DMG*D8*19630519*M~
HL*4*3*23*0~
TRN*2*93175-012547*9877281234~
NM1*03*1*SMITH*MARY~
N3*15197 BROADWAY AVENUE*APT 215~
N4*KANSAS CITY*MO*64108~
DMG*D8*19981014*F~
INS*N*19~
DTP*346*D8*20060101~
EB*1**30**GOLD 123 PLAN~
EB*L~
EB*1**1^33^35^47^86^88^98^AL^MH^UC~
EB*B**1^33^35^47^86^88^98^AL^MH^UC*HM*GOLD 123 PLAN*27*10*****Y~
EB*B**1^33^35^47^86^88^98^AL^MH^UC*HM*GOLD 123 PLAN*27*30*****N~
LS*2120~
NM1*P3*1*JONES*MARCUS****SV*0202034~
LE*2120~
SE*28*4322~


Example 2: Response to a Generic Request by a Physician for the Patient’s (Dependent) Eligibility

ISA*00*          *00*          *01*030240928      *ZZ*AV09311993     *221206*2245*^*00501*500292536*0*P*:~
GS*HB*030240928*AV01101957*20221206*2245*375976250*X*005010X279A1~
ST*271*1001*005010X279A1~
BHT*0022*11*10001234*20221206*2237~
HL*1**20*1~
NM1*PR*2*ANTHEM BLUE CROSS*****PI*040~
HL*2*1*21*1~
NM1*1P*2*PLACEHOLDER*****XX*1234567890~
HL*3*2*22*0~
TRN*2*A11A1111-A1A1-1A1A-A1A1-11AAA1AAAA1A*1111111111~
NM1*IL*1*SMITH*JOHN****MI*AAA000A00000~
REF*3H*1AAA~
REF*6P*00000A000*TECH BENEFITS PROGRAM COBRA~
REF*18*040*TECH BENEFITS PROGRAM COBRA~
N3*111 MARKET ST~
N4*BROOKLYN*NY*11111~
DMG*D8*19990909*M~
INS*Y*18~
DTP*291*RD8*20210701-20221231~
EB*1*IND*30*PR*CA GENERIC HLTH SAVINGS ACCT~
EB*D~
DTP*292*RD8*20221001-20221231~
MSG*FOR ALL SERVICES WITH HSA PLANS, THE DEDUCTIBLE MUST BE MET PRIOR TO APPLYING ANY COPAYMENT. REMINDER, PATIENT MAY HAVE HRA/HSA DOLLARS THAT CAN BE APPLIED TOWARDS THEIR DEDUCTIBLE AND OUT OF POCKET EXPENSES.~
EB*D***********Y~
DTP*292*RD8*20221001-20221231~
MSG*THIS MEMBER HAS CHRONIC PREVENTATIVE BENEFIT SERVICES FOR DIABETES, HYPERTENSION, ASTHMA, AND LIVER DISEASE/BLEEDING DISORDERS, WHICH MAY HAVE LOWER MEMBER COST SHARES.  CALL ANTHEM FOR MORE DETAILS.~
EB*D~
DTP*292*RD8*20221001-20221231~
MSG*INTERPROFESSIONAL CONSULTATION~
EB*1**AL^BZ^MH^UC^1^33^47^48^50^51^52^86^88^98*********W~
DTP*292*RD8*20221001-20221231~
EB*A*IND*BZ^UC^33^98*****.3****N~
DTP*292*RD8*20221001-20221231~
EB*A*IND*BZ^UC^33^98*****0****Y~
DTP*292*RD8*20221001-20221231~
EB*C*IND*BZ***23*0*****Y~
DTP*292*RD8*20221001-20221231~
EB*A*IND*98*****.3****N~
DTP*292*RD8*20221001-20221231~
MSG*SPECIALIST~
EB*A*IND*98*****0****Y~
DTP*292*RD8*20221001-20221231~
MSG*SPECIALIST~
EB*1**98*********W~
DTP*292*RD8*20221001-20221231~
MSG*SPECIALIST~
EB*C*IND*30***23*1111*****W~
DTP*291*RD8*20221001-20221231~
EB*C*IND*30***29*1111*****W~
DTP*291*RD8*20221001-20221231~
EB*G*IND*30***23*1111*****N~
DTP*292*RD8*20221001-20221231~
EB*G*IND*30***29*1111*****N~
EB*G*IND*30***23*1111*****Y~
DTP*292*RD8*20221001-20221231~
EB*G*IND*30***29*1111*****Y~
EB*F**33***23***VS*30**W~
DTP*292*RD8*20221001-20221231~
EB*F**33***29***VS*30**W~
EB*A*IND*47*****.3****N~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM SURGICAL UM REVIEW PROCEDURES ON ANTHEM.COM CONTACT AIM~
III*ZZ*19~
EB*A*IND*47*****.3****N~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM SURGICAL UM REVIEW PROCEDURES ON ANTHEM.COM CONTACT AIM~
III*ZZ*22~
EB*A*IND*47*****.3***U*N~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM MUSCULOSKELETAL PROGRAM PROCEDURES ON ANTHEM.COM CONTACT AIM~
III*ZZ*21~
EB*A*IND*47*****0***U*Y~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM MUSCULOSKELETAL PROGRAM PROCEDURES ON ANTHEM.COM CONTACT AIM~
III*ZZ*21~
LS*2120~
NM1*X3*2*AIM SPECIALTY HEALTH~
PER*IC**TE*8000000000~
NM1*X3*2*UTILIZATION MANAGEMENT~
PER*IC**TE*8000000000~
LE*2120~
EB*A*IND*47*****0***U*Y~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM SURGICAL UM REVIEW PROCEDURES ON ANTHEM.COM CONTACT AIM~
III*ZZ*19~
EB*A*IND*47*****0***U*Y~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM SURGICAL UM REVIEW PROCEDURES ON ANTHEM.COM CONTACT AIM~
III*ZZ*22~
EB*A*IND*48*****.3***U*N~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM MUSCULOSKELETAL PROGRAM PROCEDURES ON ANTHEM.COM CONTACT AIM~
EB*A*IND*48*****0***U*Y~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM MUSCULOSKELETAL PROGRAM PROCEDURES ON ANTHEM.COM CONTACT AIM~
LS*2120~
NM1*X3*2*AIM SPECIALTY HEALTH~
PER*IC**TE*8000000000~
NM1*X3*2*UTILIZATION MANAGEMENT~
PER*IC**TE*8000000000~
LE*2120~
EB*A*IND*50*****.3****N~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM SURGICAL UM REVIEW PROCEDURES ON ANTHEM.COM CONTACT AIM~
EB*A*IND*50*****0***U*Y~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM SURGICAL UM REVIEW PROCEDURES ON ANTHEM.COM CONTACT AIM~
LS*2120~
NM1*X3*2*AIM SPECIALTY HEALTH~
PER*IC**TE*8000000000~
LE*2120~
EB*A*IND*51^52^86*****0****W~
DTP*292*RD8*20221001-20221231~
EB*P~
MSG*UNLESS OTHERWISE REQUIRED BY STATE LAW, THIS NOTICE IS NOT A GUARANTEE OF PAYMENT. BENEFITS ARE SUBJECT TO ALL CONTRACT LIMITS AND THE MEMBER'S STATUS ON THE DATE OF SERVICE. ACCUMULATED AMOUNTS SUCH AS DEDUCTIBLE MAY CHANGE AS ADDITIONAL CLAIMS ARE PROCESSED.~
SE*114*1001~
GE*1*375976250~
IEA*1*500292536~

X12 271 Health Care Eligibility Benefit Response (X279A1)